Gestational Surrogate Application

Before proceeding to the application, there are a few requirements that must be met. Please answer all questions in a truthful and factual manner to the best of your ability by selecting “YES” or “NO” next to each question. All identifying information will be kept confidential and will not be released to potential recipients without your permission.

First Name

Last Name

Maiden name (if applicable)

Street address

City

State

Zip Code

Email Address

Home phone

Cell phone

Date of Birth

U.S. citizenship statusU.S. citizenship statusU.S. CitizenPermanent Resident/Green Card holderTemporary resident/Visa holderI am not a U.S. citizen and I do not have a Green Card or a Visa.

What is your ethnic background?What is your ethnic background?American Indian or Alaskan NativeAsianBlack or African AmericanHispanic or LatinaWhiteNative Hawaiian or Other Pacific IslanderOther

Are you a registered member of an American Indian (Native American) tribe?Are you a registered member of an American Indian (Native American) tribe?YesNo

How did you hear about Family Choice Surrogacy?How did you hear about Family Choice Surrogacy?Surrogate CoordinatorGoogleFacebookPersonal ReferralOther Search EngineFamily Choice Surrogacy’s BlogOther Social MediaMedia/News/StoryAdvertisementCraigslistFertility Clinic/DoctorSurrogate Mothers Online

Are you working with another agency?Are you working with another agency?YesNo

If yes, please provide additional information

Have you ever been rejected by another surrogacy agency?Have you ever been rejected by another surrogacy agency?YesNo

If yes, please provide the reason

Have you given birth before?Have you given birth before?YesNo

Are you actively raising your child(ren) or have actively raised?Are you actively raising your child(ren) or have actively raised?YesNo

Do you have implant birth control or have had implant birth control in last 6 months?Do you have implant birth control or have had implant birth control in last 6 months?YesNo

If yes, list date implant was removed:

Are you currently pregnant?Are you currently pregnant?YesNo

Have you had more than 2 C-sections?Have you had more than 2 C-sections?YesNo

Have you had more than 2 miscarriages?Have you had more than 2 miscarriages?YesNo

Are you currently a member of the US military?Are you currently a member of the US military?Yes, and I am currently active.Yes, but I am no longer active.Yes, my partner is currently activeYes, but my partner is no longer activeNo, I have never been a member of the U.S. militaryNo, my partner has never been a member of the U.S. military

Height

Weight (lbs.)

Have you ever tested positive for HIV?Have you ever tested positive for HIV?YesNo

Have you previously had chicken pox or received the varicella vaccine?Have you previously had chicken pox or received the varicella vaccine?I have had chicken poxI received the varicella vaccineI have not had chicken pox or the vaccine, but I am willing to be vaccinated prior to becoming a surrogateI have not had chicken pox or the vaccine, and I am NOT willing to be vaccinated prior to becoming a surrogate

Have you been vaccinated for MMR (measles, mumps, rubella)?Have you been vaccinated for MMR (measles, mumps, rubella)?YesNo, I have not had MMR vaccine, but I am willing to be vaccinated prior to becoming a surrogateNo, I have not had MMR vaccine, and I am NOT willing to be vaccinated prior to becoming a surrogate

Have you ever been immunized for Hepatitis B?Have you ever been immunized for Hepatitis B?YesNo, I have not been immunized for Hepatitis B, but I am willing to be vaccinated prior to becoming a surrogateNo, I have not been immunized for Hepatitis B, and I am NOT willing to be vaccinated prior to becoming a surrogate

Do you currently smoke cigarettes or use tobacco products?Do you currently smoke cigarettes or use tobacco products?YesNo

Were you ever a tobacco smoker? If yes, when and how long?Were you ever a tobacco smoker? If yes, when and how long?YesNo

When and how long

Do you have any history of smoking cigarettes or using tobacco products during any of your prior pregnancies?Do you have any history of smoking cigarettes or using tobacco products during any of your prior pregnancies?YesNo

Do you currently use recreational drugs or drink alcohol excessively?Do you currently use recreational drugs or drink alcohol excessively?YesNo

Do you have a history of recreational drug use or alcohol abuse? If yes, please provide detail below.Do you have a history of recreational drug use or alcohol abuse? If yes, please provide detail below.YesNo

Please provide detail.

Have you taken any anti-depressants, anti-psychotics, or anti-anxiety medications in the past six months? If yes, please provide detail below.Have you taken any anti-depressants, anti-psychotics, or anti-anxiety medications in the past six months? If yes, please provide detail below.YesNo

Please provide detail.

Have you ever had a psychiatric hospitalization? If yes, please provide detail and for how long below.Have you ever had a psychiatric hospitalization? If yes, please provide detail and for how long below.YesNo

Please provide detail and for how long.

Have you ever been diagnosed with any severe psychiatric disorder? If yes, please provide detail below.Have you ever been diagnosed with any severe psychiatric disorder? If yes, please provide detail below.YesNo

Please provide detail

Has any member of your current household ever been diagnosed with mental illness? If yes, please provide detail below.Has any member of your current household ever been diagnosed with mental illness? If yes, please provide detail below.YesNo

Please provide detail

Have you or anyone in your household been convicted of a felony?Have you or anyone in your household been convicted of a felony?YesNo

Are you or any member of your household a registered sex offender?Are you or any member of your household a registered sex offender?YesNo

Are you receiving any of the following forms of government financial assistance?Are you receiving any of the following forms of government financial assistance?Food StampsMedicaidTANF(State Welfare)WICSSIPublic HousingStudent Loans/GrantsNone of the aboveOther